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Professional Indemnity Cover
Proposal Form
The completion of this form in no way does not bind the proposer to purchase insurance nor does it bind the underwriters to give insurance Any information given
will only be passed to underwriters for the purpose of quotation renewal terms and will be treated as confidential Details provided are for automatic cover provided by the Countrywide master policy Professional Indemnity policy
Name
Establishment Date
Address
Details of all Principals Partners or Directors
Name Age Qualifications (attach CVrsquos if available)
Estimates for work undertaken by Countrywide Tax and Trust Corporation Limited or documentation
produced using software developed by Countrywide Tax and Trust Corporation Limited
UK USACanada Other Total
Estimated Gross Fees for the next financial year
Largest Fee from any one client
Cover is provided in respect of document production undertaken by Countrywide Tax and Trust Corporation
only except contract lsquoDrsquo Please provide details paid fees to other professional providers for the last financial
year pound
Details of the 3 largest contracts in the last 5 financial years and provide details largest current projects (if new
business) for Countrywide Tax and Trust Corporation Limited
Client Description Contract Value Fee
1
2
3
2 Have any claims in respect of the risks to which this form relates ever been made against the
business or any of the principals partners or directors YESNO
Are any of the principals partners or directors AFTER FULL ENQUIRY aware of any
circumstance that might give rise to any such claim YESNO
Has any proposal in respect of the risks to which this form relates ever been declined or has any such
insurance ever been cancelled or renewal refused YESNO
pound pound
poundpound
pound pound
pound pound
If the answer to any of the above 3 questions is YES then please provide full details on a separate sheet
Other Material Information
Does the firm currently hold Professional Indemnity Insurance for this class of business YES NO
If Yes - Insurer helliphelliphelliphelliphelliphelliphelliphellip Renewal Date
Date cover originally placed where cover has been continuous sincehelliphelliphellip
You have a duty to give a fair presentation of the risk to an insurer based on your reasonable understanding of the risks to your business This is one which clearly discloses all material facts which your senior management and the persons responsible for arranging your insurance know or ought to know following a reasonable search of information available to them It should include all facts that would influence the judgement of the insurer or that would put the insurer on notice that it needs to make further enquiries A material circumstance is defined as
Special or unusual circumstances relating to the risk
Any particular concerns which led you to seek insurance cover for the risk and
Anything which those concerned with the class of insurance and field of activity in question would generally understand as being something that would be dealt with in a fair presentation of risks for this type of insurance
If you fail to disclose information misrepresent any fact which may influence the insurerrsquos decision to accept the risk or the terms offered or fail to make a fair presentation to an insurer this could invalidate the policy and mean that claims may not be paid in fullrdquo
Signature of Proposer(s) ________________ Title of signatory ________ Date _____ _____ _____
Professional Indemnity Cover
Proposal Form
The completion of this form in no way does not bind the proposer to purchase insurance nor does it bind the underwriters to give insurance Any information given will only be passed to underwriters for the purpose of quotation renewal terms and will be treated as confidential Details provided are for automatic cover provided by the Countrywide master policy Professional Indemnity policy
Name Establishment Date
Address
Details of all Principals Partners or Directors Name Age Qualications (attach CVrsquos if a vailable)
Estimates for work undertaken by Countrywide Tax and Trust Corporation Limited or documentation produced using software developed by Countrywide Tax and Trust Corporation Limited
UK USACanada Other Total Estimated Gross Fees for the next financial year pound pound pound pound
Largest Fee from any one client
pound pound pound pound
Cover is provided in respect of document production undertaken by Countrywide Tax and Trust Corporation only except contract lsquoDrsquo Please provide details paid fees to other professional providers for the last financial year pound
Individual Advisor insert your own name Individual Advisor but trading as - insert your name and your TA name
Partnerships include both the trading name and partners names Ltd company ndash full company name
Oce address (if applicable) or home address
Date started trading
Complete ONLY if a Company NA - no CVrsquos need to be attached Qualications are irrelevant as this
business is unregulated
Where there are directors this section must be completed regardless of whether they are instruction takers
For estate planning work only- so if this is your rst year this can be blank
Gross = the total (including commission amp processing fees) the fee you have charged all clients The only thing you can deduct is VAT
Quotation cannot be provided without this box being completed
If you are new to the business then
leave this blank
Blank for contracts BampC This should only be completed for contract d The insurer needs
of work being undertaken by a third party
If the answer to any of the above 3 questions is YES then please provide full details on a separate sheet Other Material Information
Does the firm currently hold Professional Indemnity Insurance for this class of business YES NO If Yes - Insurer helliphelliphelliphelliphelliphelliphelliphellip Renewal Date Date cover originally placed where cover has been continuous sincehelliphelliphellip You have a duty to give a fair presentation of the risk to an insurer based on your reasonable understanding of the risks to your business This is one which clearly discloses all material facts which your senior management and the persons responsible for arranging your insurance know or ought to know following a reasonable search of information available to them It should include all facts that would inuence the judgement of the insurer or that would put the insurer on notice that it needs to make further enquiries A material circumstance is defined as
Special or unusual circumstances relating to the risk Any particular concerns which led you to seek insurance cover for the risk and Anything which those concerned with the class of insurance and eld of activity in question
would generally understand as being something that would be dealt with in a fair presentation of risks for this type of insurance
If you fail to disclose information misrepresent any fact which may inuence the insurerrsquos decision to accept the risk or the terms oered or fail to make a fair presentation to an insurer this could invalidate the policy and mean that claims may not be paid in fullrdquo
Signature of Proposer(s) ________________ Title of signatory ________ Date _____ _____ _____
Details of the 3 largest contracts in the last 5 financial years and provide details largest current projects (if new business) for Countrywide Tax and Trust Corporation Limited Client Description Contract Value Fee 1
2
3
Have any claims in respect of the risks to which this form relates ever been made against the business or any of the principals partners or directors YESNO Are any of the principals partners or directors AFTER FULL ENQUIRY aware of any circumstance that might give rise to any such claim YESNO Has any proposal in respect of the risks to which this form relates ever been declined or has any such insurance ever been cancelled or renewal refused YESNO
This can be blank if you are a new Advisor If not complete
for three biggest clients
Total fee paid by client
Commission
If the answer to any of the above 3 questions is YES then please provide full details on a separate sheet
Other Material Information
Does the firm currently hold Professional Indemnity Insurance for this class of business YES NO
If Yes - Insurer helliphelliphelliphelliphelliphelliphelliphellip Renewal Date
Date cover originally placed where cover has been continuous sincehelliphelliphellip
You have a duty to give a fair presentation of the risk to an insurer based on your reasonable understanding of the risks to your business This is one which clearly discloses all material facts which your senior management and the persons responsible for arranging your insurance know or ought to know following a reasonable search of information available to them It should include all facts that would influence the judgement of the insurer or that would put the insurer on notice that it needs to make further enquiries A material circumstance is defined as
Special or unusual circumstances relating to the risk
Any particular concerns which led you to seek insurance cover for the risk and
Anything which those concerned with the class of insurance and field of activity in question would generally understand as being something that would be dealt with in a fair presentation of risks for this type of insurance
If you fail to disclose information misrepresent any fact which may influence the insurerrsquos decision to accept the risk or the terms offered or fail to make a fair presentation to an insurer this could invalidate the policy and mean that claims may not be paid in fullrdquo
Signature of Proposer(s) ________________ Title of signatory ________ Date _____ _____ _____
Professional Indemnity Cover
Proposal Form
The completion of this form in no way does not bind the proposer to purchase insurance nor does it bind the underwriters to give insurance Any information given will only be passed to underwriters for the purpose of quotation renewal terms and will be treated as confidential Details provided are for automatic cover provided by the Countrywide master policy Professional Indemnity policy
Name Establishment Date
Address
Details of all Principals Partners or Directors Name Age Qualications (attach CVrsquos if a vailable)
Estimates for work undertaken by Countrywide Tax and Trust Corporation Limited or documentation produced using software developed by Countrywide Tax and Trust Corporation Limited
UK USACanada Other Total Estimated Gross Fees for the next financial year pound pound pound pound
Largest Fee from any one client
pound pound pound pound
Cover is provided in respect of document production undertaken by Countrywide Tax and Trust Corporation only except contract lsquoDrsquo Please provide details paid fees to other professional providers for the last financial year pound
Individual Advisor insert your own name Individual Advisor but trading as - insert your name and your TA name
Partnerships include both the trading name and partners names Ltd company ndash full company name
Oce address (if applicable) or home address
Date started trading
Complete ONLY if a Company NA - no CVrsquos need to be attached Qualications are irrelevant as this
business is unregulated
Where there are directors this section must be completed regardless of whether they are instruction takers
For estate planning work only- so if this is your rst year this can be blank
Gross = the total (including commission amp processing fees) the fee you have charged all clients The only thing you can deduct is VAT
Quotation cannot be provided without this box being completed
If you are new to the business then
leave this blank
Blank for contracts BampC This should only be completed for contract d The insurer needs
of work being undertaken by a third party
If the answer to any of the above 3 questions is YES then please provide full details on a separate sheet Other Material Information
Does the firm currently hold Professional Indemnity Insurance for this class of business YES NO If Yes - Insurer helliphelliphelliphelliphelliphelliphelliphellip Renewal Date Date cover originally placed where cover has been continuous sincehelliphelliphellip You have a duty to give a fair presentation of the risk to an insurer based on your reasonable understanding of the risks to your business This is one which clearly discloses all material facts which your senior management and the persons responsible for arranging your insurance know or ought to know following a reasonable search of information available to them It should include all facts that would inuence the judgement of the insurer or that would put the insurer on notice that it needs to make further enquiries A material circumstance is defined as
Special or unusual circumstances relating to the risk Any particular concerns which led you to seek insurance cover for the risk and Anything which those concerned with the class of insurance and eld of activity in question
would generally understand as being something that would be dealt with in a fair presentation of risks for this type of insurance
If you fail to disclose information misrepresent any fact which may inuence the insurerrsquos decision to accept the risk or the terms oered or fail to make a fair presentation to an insurer this could invalidate the policy and mean that claims may not be paid in fullrdquo
Signature of Proposer(s) ________________ Title of signatory ________ Date _____ _____ _____
Details of the 3 largest contracts in the last 5 financial years and provide details largest current projects (if new business) for Countrywide Tax and Trust Corporation Limited Client Description Contract Value Fee 1
2
3
Have any claims in respect of the risks to which this form relates ever been made against the business or any of the principals partners or directors YESNO Are any of the principals partners or directors AFTER FULL ENQUIRY aware of any circumstance that might give rise to any such claim YESNO Has any proposal in respect of the risks to which this form relates ever been declined or has any such insurance ever been cancelled or renewal refused YESNO
This can be blank if you are a new Advisor If not complete
for three biggest clients
Total fee paid by client
Commission
Professional Indemnity Cover
Proposal Form
The completion of this form in no way does not bind the proposer to purchase insurance nor does it bind the underwriters to give insurance Any information given will only be passed to underwriters for the purpose of quotation renewal terms and will be treated as confidential Details provided are for automatic cover provided by the Countrywide master policy Professional Indemnity policy
Name Establishment Date
Address
Details of all Principals Partners or Directors Name Age Qualications (attach CVrsquos if a vailable)
Estimates for work undertaken by Countrywide Tax and Trust Corporation Limited or documentation produced using software developed by Countrywide Tax and Trust Corporation Limited
UK USACanada Other Total Estimated Gross Fees for the next financial year pound pound pound pound
Largest Fee from any one client
pound pound pound pound
Cover is provided in respect of document production undertaken by Countrywide Tax and Trust Corporation only except contract lsquoDrsquo Please provide details paid fees to other professional providers for the last financial year pound
Individual Advisor insert your own name Individual Advisor but trading as - insert your name and your TA name
Partnerships include both the trading name and partners names Ltd company ndash full company name
Oce address (if applicable) or home address
Date started trading
Complete ONLY if a Company NA - no CVrsquos need to be attached Qualications are irrelevant as this
business is unregulated
Where there are directors this section must be completed regardless of whether they are instruction takers
For estate planning work only- so if this is your rst year this can be blank
Gross = the total (including commission amp processing fees) the fee you have charged all clients The only thing you can deduct is VAT
Quotation cannot be provided without this box being completed
If you are new to the business then
leave this blank
Blank for contracts BampC This should only be completed for contract d The insurer needs
of work being undertaken by a third party
If the answer to any of the above 3 questions is YES then please provide full details on a separate sheet Other Material Information
Does the firm currently hold Professional Indemnity Insurance for this class of business YES NO If Yes - Insurer helliphelliphelliphelliphelliphelliphelliphellip Renewal Date Date cover originally placed where cover has been continuous sincehelliphelliphellip You have a duty to give a fair presentation of the risk to an insurer based on your reasonable understanding of the risks to your business This is one which clearly discloses all material facts which your senior management and the persons responsible for arranging your insurance know or ought to know following a reasonable search of information available to them It should include all facts that would inuence the judgement of the insurer or that would put the insurer on notice that it needs to make further enquiries A material circumstance is defined as
Special or unusual circumstances relating to the risk Any particular concerns which led you to seek insurance cover for the risk and Anything which those concerned with the class of insurance and eld of activity in question
would generally understand as being something that would be dealt with in a fair presentation of risks for this type of insurance
If you fail to disclose information misrepresent any fact which may inuence the insurerrsquos decision to accept the risk or the terms oered or fail to make a fair presentation to an insurer this could invalidate the policy and mean that claims may not be paid in fullrdquo
Signature of Proposer(s) ________________ Title of signatory ________ Date _____ _____ _____
Details of the 3 largest contracts in the last 5 financial years and provide details largest current projects (if new business) for Countrywide Tax and Trust Corporation Limited Client Description Contract Value Fee 1
2
3
Have any claims in respect of the risks to which this form relates ever been made against the business or any of the principals partners or directors YESNO Are any of the principals partners or directors AFTER FULL ENQUIRY aware of any circumstance that might give rise to any such claim YESNO Has any proposal in respect of the risks to which this form relates ever been declined or has any such insurance ever been cancelled or renewal refused YESNO
This can be blank if you are a new Advisor If not complete
for three biggest clients
Total fee paid by client
Commission
If the answer to any of the above 3 questions is YES then please provide full details on a separate sheet Other Material Information
Does the firm currently hold Professional Indemnity Insurance for this class of business YES NO If Yes - Insurer helliphelliphelliphelliphelliphelliphelliphellip Renewal Date Date cover originally placed where cover has been continuous sincehelliphelliphellip You have a duty to give a fair presentation of the risk to an insurer based on your reasonable understanding of the risks to your business This is one which clearly discloses all material facts which your senior management and the persons responsible for arranging your insurance know or ought to know following a reasonable search of information available to them It should include all facts that would inuence the judgement of the insurer or that would put the insurer on notice that it needs to make further enquiries A material circumstance is defined as
Special or unusual circumstances relating to the risk Any particular concerns which led you to seek insurance cover for the risk and Anything which those concerned with the class of insurance and eld of activity in question
would generally understand as being something that would be dealt with in a fair presentation of risks for this type of insurance
If you fail to disclose information misrepresent any fact which may inuence the insurerrsquos decision to accept the risk or the terms oered or fail to make a fair presentation to an insurer this could invalidate the policy and mean that claims may not be paid in fullrdquo
Signature of Proposer(s) ________________ Title of signatory ________ Date _____ _____ _____
Details of the 3 largest contracts in the last 5 financial years and provide details largest current projects (if new business) for Countrywide Tax and Trust Corporation Limited Client Description Contract Value Fee 1
2
3
Have any claims in respect of the risks to which this form relates ever been made against the business or any of the principals partners or directors YESNO Are any of the principals partners or directors AFTER FULL ENQUIRY aware of any circumstance that might give rise to any such claim YESNO Has any proposal in respect of the risks to which this form relates ever been declined or has any such insurance ever been cancelled or renewal refused YESNO
This can be blank if you are a new Advisor If not complete
for three biggest clients
Total fee paid by client
Commission
